Jill Yielder

The relationship between academic assessment and psychological distress among medical students: a systematic review

A systematic review was conducted to determine the relationship between academic assessment and medical student psychological distress with the aim of informing assessment practices. A systematic literature search of six electronic databases (Medline, Medline IN PROCESS, PubMed, EMBASE, Psychinfo, ERIC) from 1991 to May 2014 was completed. Articles focusing on academic assessment and its relation to stress or anxiety of medical students were included. From 3,986 potential titles, 82 full-text articles were assessed for eligibility, and 23 studies met review inclusion criteria. Studies focused on assessment stress or anxiety, and assessment performance. Consistent among the studies was the finding that assessment invokes stress or anxiety, perhaps more so for female medical students. A relationship may exist between assessment stress or anxiety and impaired performance. Significant risks of bias were common in study methodologies. There is evidence to suggest academic assessment is associated with psychological distress among medical students. However, differences in the types of measures used by researchers limited our ability to draw conclusions about which methods of assessment invoke greater distress. More rigorous study designs and the use of standardized measures are required. Future research should consider differences in students’ perceived significance of assessments, the psychological effects of constant exposure to assessment, and the role of assessment in preparing students for clinical practice.

Progress testing in the medical curriculum: students’ approaches to learning and perceived stress

BackgroundProgress Tests (PTs) draw on a common question bank to assess all students in a programme against graduate outcomes. Theoretically PTs drive deep approaches to learning and reduce assessment-related stress. In 2013, PTs were introduced to two year groups of medical students (Years 2 and 4), whereas students in Years 3 and 5 were taking traditional high-stakes assessments. Staged introduction of PTs into our medical curriculum provided a time-limited opportunity for a comparative study. The main purpose of the current study was to compare the impact of PTs on undergraduate medical students’ approaches to learning and perceived stress with that of traditional high-stakes assessments. We also aimed to investigate the associations between approaches to learning, stress and PT scores.MethodsUndergraduate medical students (N = 333 and N = 298 at Time 1 and Time 2 respectively) answered the Revised Study Process Questionnaire (R-SPQ-2F) and the Perceived Stress Scale (PSS) at two time points to evaluate change over time. The R-SPQ-2F generated a surface approach and a deep approach score; the PSS generated an overall perceived stress score.ResultsWe found no significant differences between the two groups in approaches to learning at either time point, and no significant changes in approaches to learning over time in either cohort. Levels of stress increased significantly at the end of the year (Time 2) for students in the traditional assessment cohort, but not in the PT cohort. In the PT cohort, surface approach to learning, but not stress, was a significant negative predictor of students’ PT scores.ConclusionsWhile confirming an association between surface approaches to learning and lower PT scores, we failed to demonstrate an effect of PTs on approaches to learning. However, a reduction in assessment-associated stress is an important finding.

Establishing radiation therapy advanced practice in New Zealand.

Advanced practice (AP) is of increasing interest to many radiation therapists (RTs) both nationally and internationally. In New Zealand, initial research (2005–2008) showed strong support for the development of an AP role for medical radiation technologists (MRTs). Here, we report on a nationwide survey in which RTs validated and prioritised nine AP profiles for future development.

Establishing advanced practice for medical imaging in New Zealand

This article presents the outcome and recommendations following the second stage of a role development project conducted on behalf of the New Zealand Institute of Medical Radiation Technology (NZIMRT). The study sought to support the development of profiles and criteria that may be used to formulate Advanced Scopes of Practice for the profession. It commenced in 2011, following on from initial research that occurred between 2005 and 2008 investigating role development and a possible career structure for medical radiation technologists (MRTs) in New Zealand (NZ).

Creating our future: conformity or change?

In the June 2014 issue of the Journal of Medical Radiation Sciences, an article by Neep et al.1 is on the subject of ‘frontline radiographer commenting’, in the context of abnormalities of the musculoskeletal system due to trauma. I would like to use this article as a timely catalyst to debate some of the issues that the profession is currently facing. In this editorial the term ‘radiographer’ will be used to represent the diagnostic sector of the profession, while noting that in New Zealand medical imaging technologist is the term designated by the Medical Radiation Technologists Board (MRTB). Medical imaging and radiation therapy in both New Zealand and Australia have been exploring for some years the possibility of changing roles and career progression frameworks in line with international developments. These developments have seen radiographers and radiation therapists extending their practice both within their own scopes of practice (role expansion) and into areas previously designated as roles of doctors or other health professionals (role extension). These developments have been in part to reflect the changing nature of health provision, with an advanced practice framework having the potential to be of real benefit to patients, and in part to enable professional development for an important and highly skilled sector of the health workforce. This change has been particularly apparent in the United Kingdom over the past two decades, a significant length of time that has allowed for acceptance, consolidation and research to be undertaken to support their initiatives. This is not yet the case in Australia or New Zealand, where progress has been slower and has yet to achieve a level of acceptance. In New Zealand progress has been made based on research conducted initially between 2005 and 2008, investigating role development and a possible career structure. The recommendations from this research were formally accepted by the New Zealand Institute of Medical Radiation Technology (NZIMRT) in 2009 and led to further research conducted between 2010 and 2013, developing profiles and criteria for the formulation of advanced scopes of practice towards the establishment of an advanced practitioner role. The registration board in New Zealand, the MRTB, currently has the development of an advanced scope of practice under consideration as it progresses with reformulation of all the scopes of practice for the profession. In Australia, a proposed pathway to advanced practice has been distributed to members of the Australian Institute of Radiography (AIR) for consultation (see http://www.air.asn.au/advanced.php) and its roll out is expected to commence in the near future. It was based on a report released by Professor Ian Freckleton SC and the Inter-professional Advisory Team in April 2012. To this end, the AIR has recently released a call for applications for advanced practitioner accreditation via the champion pathway. In this context, Neep et al.s article explores radiographer perceptions of their readiness to detect and comment on abnormalities of the axial and appendicular skeleton following trauma, as well as their preferences for two alternative forms of delivery of image interpretation education. It has been well documented, as described in both Neep et al.s article and the commentary also included in this issue by Woznitza,2 that radiographers are capable of high levels of sensitivity and specificity in the reporting of radiographs, not to mention the many other forms of role extension that have been incorporated in advanced practitioner roles in the United Kingdom. Given that there is a solid evidence base to support role extension and the formulation of advanced practitioner roles, the lack of confidence shown by radiographers about their abilities and their reluctance to actually describe what they have detected, raises some professionally focused questions for debate. Woznitzas commentary reports the findings of Coleman and Piper,3 who compared the confidence and accuracy of nurse practitioners, junior doctors and radiographers reporting trauma radiographs. They found that radiographers reported lower confidence, even though they had the highest average score and were the only group whose level of confidence correlated with their accuracy. As has been identified previously,4–7 there is a culture of subservience and apathy prevalent in the profession, largely due to the background of medical dominance that has persisted since the early 1900s when a hierarchal system was created within radiology departments, bringing about the limitation of the radiographers role.8,9 Lewis et al.6 maintain that radiographers report feelings of intimidation, under-appreciation and worthlessness, that they feel ‘overlooked’, and these factors have translated into the ‘just the radiographer’ syndrome. While this article was written 8 years ago, this form of identity based on an inferiority complex can still be evidenced in attitudes towards advanced practice, for example, as seen in qualitative comments elicited in the recent medical imaging research for the NZIMRT.7 It could be postulated that this may be one of the factors lying behind the lack of confidence of participants describing (as opposed to detecting) abnormalities that characterised the findings of Neep et al.1 It has also been suggested4,5 that radiographers have been socialised into a culture of compliance in order to be accepted as members of the broader radiology team. Conformity and compliance generally lead to conventional behaviour and are not conducive to innovation, risk-taking and improvement. This form of workplace culture does not support high levels of job satisfaction, self-esteem or confidence. Does this mean that given the opportunity to develop and advance, there is likely to be a backlash of resistance? Does this perhaps relate to why radiographers and radiation therapists in Australia and New Zealand have been slow to embrace the changes necessary to support career progression? If professional identity is formed around being ‘just the radiographer’, then how can a practitioner dare to stand up and offer an opinion that may be taken seriously by medical staff and other health professionals? Unfortunately, remaining restricted in a role undermines motivation and encourages ‘mindless’ practice.4 This professional culture does not encourage critically reflective practice,5 teamwork or the ability to effect needed change. Apathy also has an effect on a practitioners willingness to engage in the life-long learning (including research) required to fully engage as a professional. Neep et al.s article suggests that the participants in the research study were willing to consider a short 2-day (or equivalent) course of targeted image interpretation training to enable them to take on a radiographer commenting role. At the same time it was suggested that the more formal postgraduate requirements for image reporting may be found ‘inaccessible due to large time requirements and a substantial financial commitment’.1 While there was a strong theme evident in the New Zealand role development research10 that indicated a desire for change that would enhance their professional status, there were many participants who expressed resistance to engaging in further study or taking on additional responsibilities. It is a case of the philosophical ‘chicken-and-egg’ problem – if radiographers and radiation therapists engage in further education their confidence will improve and they will feel able to take on extended roles that befit their knowledge and skills. How can they be empowered to adopt an active approach to their future, which means being willing to put in the time, energy and financial commitment to lead change, even where the future is still unknown? To ensure the future of the profession, it is time for radiographers and radiation therapists in both countries to stand up and insist on being seen, respected and having a profile as health professionals rather than being conceptualised as ‘allied health technicians’ (to this end it is unfortunate that in New Zealand the term ‘technologist’ is still used, along with the message this sends). Medical imaging and radiation therapy are rapidly developing professions that need motivated and active practitioners if reciprocity with our international colleagues and with other health professions is to be upheld. Neep et al.s article is a timely reminder that while progress is being made, some radiographers and radiation therapists are still finding a move outside their comfort zone challenging, despite the large body of evidence that they are capable of making that change. At the same time, there are many practitioners in both countries who indicate willingness to champion local change. Our professional bodies (AIR and NZIMRT) need to find ways to encourage and engage these practitioners, both to create change in the professional culture and to progress an advanced practitioner framework.

Progress Testing for Medical Students at The University of Auckland: Results from The First Year of Assessments

Background Progress testing is a method of assessing longitudinal progress of students using a single best answer format pitched at the standard of a newly graduated doctor. Aim To evaluate the results of the first year of summative progress testing at the University of Auckland for Years 2 and 4 in 2013. SUBJECTS: Two cohorts of medical students from Years 2 and 4 of the Medical Program. Methods A survey was administered to all involved students. Open text feedback was also sought. Psychometric data were collected on test performance, and indices of reliability and validity were calculated. Results The three tests showed increased mean scores over time. Reliability of the assessments was uniformly high. There was good concurrent validity. Students believe that progress testing assists in integrating science with clinical knowledge and improve learning. Year 4 students reported improved knowledge retention and deeper understanding. Conclusion Progress testing has been successfully introduced into the Faculty for two separate year cohorts and results have met expectations. Other year cohorts will be added incrementally. Recommendation Key success factors for introducing progress testing are partnership with an experienced university, multiple and iterative briefings with staff and students as well as demonstrating the usefulness of progress testing by providing students with detailed feedback on performance.

Assessing the Development of Medical Students’ Personal and Professional Skills by Portfolio

The introduction of a new domain of learning for Personal and Professional Skills in the medical program at the University of Auckland in New Zealand has involved the compilation of a portfolio for assessment. This departure from the traditional assessment methods predominantly used in the past has been challenging to design, introduce, and maintain as a relevant and authentic assessment method. We present the portfolio format along with the process for its introduction and appraise the challenges, strengths, and limitations of the approach within the context of the current literature. We then outline a cyclical model of evaluation used to monitor and fine-tune the portfolio tasks and implementation process, in response to student and assessor feedback. The portfolios have illustrated the level of insight, maturity, and synthesis of personal and professional qualities that students are capable of achieving. The Auckland medical program strives to foster these qualities in its students, and the portfolio provides an opportunity for students to demonstrate their reflective abilities. Moreover, the creation of a Personal and Professional Skills domain with the portfolio as its key assessment emphasizes the importance of reflective practice and personal and professional development and gives a clear message that these are fundamental longitudinal elements of the program.

Depression in medical students: current insights

Medical students are exposed to multiple factors during their academic and clinical study that have been shown to contribute to high levels of depression, anxiety, and stress. The purpose of this article was to explore the issue of depression in the medical student population, including prevalence, causes, and key issues, along with suggestions for early identification and support from one medical school in New Zealand. After establishing that the prevalence of depression is higher for medical students than the general population, the key issues explored include assessment used in the program, characteristics of the student population (such as Type A personality and perfectionism), resilience, selection procedures, students’ motivation, and the nature of the clinical environment. This review includes several recommendations to improve students’ psychological health such as positioning well-being within an overarching comprehensive workplace wellness model and integrating peer and faculty-led support into the day-to-day running of the institution. It also highlights the advantages of the addition of a well-being curriculum, as skills to prevent and manage distress and depression are relevant in supporting the competencies required by medical practitioners. It concludes that medical schools need wide-ranging strategies to address the complexities associated with the particular student population attracted to medicine and calls for educators to act, by noticing opportunities where they can introduce such initiatives into their medical programs.

Student personality and learning styles: A comparison between radiation therapy and medical imaging undergraduate students in New Zealand

This study investigated the learning styles and personality type of undergraduate radiation therapy students at the University of Otago, Wellington (UOW) in New Zealand (NZ) to ascertain whether there is a pattern evidenced for this group and how that might compare with NZ medical imaging students. All students enrolled in the first year of the Bachelor of Radiation Therapy degree from 2014 to 2016 at the UOW were invited to participate in this research. The test tool was the Paragon Learning Style Inventory (PLSI), which is a standardised questionnaire adapted from the Myers-Briggs Type Indicator (MBTI). All students who participated in the workshops consented for their data to be used for this project. The current study is longitudinal, and will continue for five years in total. The initial findings indicate that the cohorts of RT students exhibit personality and learning style preferences similar in Introversion/Extraversion and Thinking/Feeling to the proportion expected in the normal population. However, the Sensing/Intuition and Judging/Perceiving dichotomies show some similarities to the medical imaging students studied, who fell considerably outside that expected in the normal population. Overall, the dominant preference combinations identified, although different in degree, were similar to those of medical imaging students. The continuation of the radiation therapy study is important to ascertain more fully whether the results are particular to these cohorts of students or are trending towards showing a pattern of personality and learning style within the profession.

A qualitative exploration of student perceptions of the impact of progress tests on learning and emotional wellbeing

BackgroundProgress testing was introduced to the MBChB programme at the University of Auckland in 2013. As there has been a focus in published literature on aspects relating to the format or function of progress tests, the purpose of this study was to explore a qualitative student perspective on the introduction of progress testing and its impact on approaches to learning and perceived stress.MethodsThis article presents the qualitative aspects of a longitudinal evaluation study. The qualitative data were derived from eight focus groups of Year 2–5 medical students in the University of Auckland medical programme.ResultsTwo themes, ‘Impact on Learning’ and ‘Emotional Wellbeing’ and their subthemes offered insight into student perceptions and behaviour. Students described a variety of learning responses to progress testing that clustered around the employment of a range of learning strategies based on their experience of sitting progress tests and their individualised feedback. A range of emotional responses were also expressed, with some finding progress tests stressful, while others enjoyed not needing to intensively cram before the tests.ConclusionsProgress tests appear to influence the approach of students to their learning. They employ a mix of learning strategies, shaped by their performance, individualised feedback and the learning environment. While students expressed some stress and anxiety with respect to sitting progress tests, this form of testing was viewed by these students as no worse, and sometimes better than traditional assessments.